RUQ pain

Question 1

Differentials for RUQ pain in a young woman

Answer 1

Biliary colic
Cholecystitis
Duodenal ulcer
Pancreatitis
Basal pneumonia 
Ascending cholangitis
Gastric ulcer
Small bowel obstruction
Appendicits 
Hepatitis
Pyelonephritis

Question 2

What differentials would be more common in an elderly patient

Answer 2

Pneumonia
Cancer
Vascular: aortic dissection, AAA, inferior MI

Question 3

After characterising the pain, what other questions should be asked about RUQ

Answer 3

Any symptoms other than pain
When did they last open their bowels - was it flatus or wind
Any changes in bowel habits or changes in stool
Are they pregnant

Question 4

What are the considerations/differentials for pain in a pregnancy woman

Answer 4

Pre-eclampsia
Cholestasis of pregnancy
Ectopic pregnancy

Question 5

What features would be looked for on exam

Answer 5

Jaundice
Bruising and discolouration around the flank 
Pulsatile expansile mass
Murphy's sign 
Peritonitis 
Signs of small bowel obstruction

Question 6

What bloods would be requested for suspected cholecystits/RUQ pain

Answer 6

FBC - look for WCC
Amylase or lipase - pancreatitis
LFTs
Bilirubin - unconjugated vs conjugated

Question 7

What imaging would be requested for suspected cholecystitis/RUQ pain

Answer 7

CXR (erect) - pneumoperitoneum
USS pancreas, common bile duct, gallbladder
Abdominal radiograph

Question 8

What is Charcot’s triad

Answer 8

Signs for ascending cholangitis
Fever with rigors
Jaundice
RUQ pain

Question 9

What are the complications of cholecystitis

Answer 9

Empyema
Cholecystoduodenal fistula which allows bowel air into the gall bladder or stones into the small bowel -> ileus
Ascending cholangitis

Question 10

What is the management of ascending cholangitis

Answer 10

Obtain blood cultures
Broad spectrum antibiotics 
ERCP drainage 
Monitoring - NBM, IV fluids and analgesia
Elective cholecystectomy

Question 11

What is the association of vitamin K and distinguishing between obstructive jaundice and liver disease

Answer 11

Vitamin K is involved in Factor II, VII, IX and X production (measured by PT)

Parenteral vit K would not affect PT if there is liver disease
Parenteral vit K would correct PT if there is obstruction

Question 12

What are the types of gall stones and which patients are predisposed to them

Answer 12

Bile pigment (5%) - from RBC breakdown - those with haemolytic anaemias pre-disposed
Cholesterol (20%) - 5F's, contraceptive therapy, Crohn's 
Mixed composition (75%)

Question 13

What percentage of gallstones compared to renal/uteric stones are radio-opaque

Answer 13

Gallstones - 10%

Renal/uteric - 90%

Question 14

What are the complications of gallstones

Answer 14

Biliary colic
Cholecystitis
Empyema
Mucocoele
Cholangiocarcinoma
Choledocholethiasis 
Ascending cholangitis
Acute pancreatitis 
Gallstone ileus

Question 15

Explain why biliary colic is exacerbated by fatty food consumption

Answer 15

Cholecystokinin (CKK) is released from the duodenum in response to fatty foods, which stimulates the secretion of digestive enzymes from the pancreas AND contraction of the gallbladder, which would exacerbate biliary colic

Question 16

What is Calot’s triangle

Answer 16

Anatomical zone used to define the usual path of the cystic artery, the cystic duct and common hepatic duct

Superior border - liver
Inferior border - cystic duct
medial border - common hepatic duct

Question 17

What is Mirizzi’s syndrome

Answer 17

Stone in Hartmann’s pouch that presses extrinsically on the CBD

Question 18

Which part of the duodenum does the pancreatic duct open into

Answer 18

The second part via the ampulla of Vater

Question 19

What are the risks of ERCP

Answer 19

Bleeding
Perforation of the biliary tree
Cholangitis
Pancreatitis